Rebound of Gonorrhea after Lifting of COVID-19 Preventive Measures, England

After lifting of all COVID-19 preventive measures in England in July 2021, marked, widespread increases in gonorrhea diagnoses, but not testing numbers, were observed, particularly in persons 15–24 years of age. Continued close surveillance and public health messaging to young persons are needed to control and prevent gonorrhea transmission.

T he COVID-19 pandemic caused a substantial dis- ruption of sexual health services (SHS) in England (including reduced testing), contributing to a 33.5% decrease in new sexually transmitted infection (STI) diagnoses in 2020 (n = 311,480) compared with 2019 (n = 468,260) (1).In July 2021, all COVID-19 restrictions associated with the third and final lockdown in England were lifted (2), normal social mixing was permitted, and a rebound in SHS occurred; a 23.8% increase in new STI diagnoses was observed in 2022 (n = 392,453) compared with those in 2021 (n = 317,022) (1).Of the most commonly diagnosed STIs, the largest proportional increase occurred for gonorrhea, caused by infection with Neisseria gonorrhoeae bacteria.The number of new gonorrhea diagnoses increased by 50.3% in 2022 (n = 82,592) compared with 2021 (n = 54,961) (1).We describe trends for gonorrhea testing and diagnosis in England after all COVID-19 control measures were lifted and explore how those differed among populations.

The Study
In England, all STI tests and diagnoses from SHS are captured by the Genitourinary Medicine Clinic Activity Dataset STI Surveillance System (3).We analyzed data on gonorrhea tests and diagnoses during January 1, 2019-December 31, 2022.To prevent double counting, we only counted 1 test or diagnosis per SHS user within a 42-day period.We examined quarterly trends, disaggregated by age group (15-24, 25-34, 35-44, and >45 years of age), gender and sexual orientation (gay, bisexual, and other men who have sex with men [MSM]; heterosexual men; women who have sex with men [WSM]; and women who only have sex with women), and local authority districts of residence.We did not include records with missing demographic data in their respective analysis.We analyzed data by using Stata version 16.1 software (StataCorp LLC, https://www.stata.com).No ethics approval was needed for this study because we used routine surveillance data.
After lifting of COVID-19-related restrictions, the number of gonorrhea tests increased by 5.6% from quarter (Q) 3 of 2021 (n = 483,717) to the end of Q4 of 2022 (n = 510,792).Gonorrhea diagnoses increased by 63.8% (13,715 to 22,471) during the same period (Figure 1, panel A).The total number of gonorrhea diagnoses in 2022 was the highest on record, although testing remained just below 2019 levels.Test positivity increased to the highest point within the 4-year study period during 2022 Q4 (4.4%) from a low point in 2021 Q3 (2.8%) (Figure 1, panel B).
Increases in gonorrhea diagnoses began immediately after COVID-19-related restrictions were lifted and were most notable in young persons, 15-24 years of age, who saw a 141.3% increase (3,747

Conclusions
National surveillance data showed an increase in gonorrhea diagnoses in England after the cessation of social restrictions in summer 2021.Increases were observed among persons of all age groups, genders, and sexual orientations but particularly among persons 15-24 years of age and those who identified as heterosexual.
Testing did not increase as markedly as diagnoses after the removal of COVID-19 lockdown restrictions, suggesting that a true increase in gonorrhea transmission existed within the population.Changes in diagnosis numbers could potentially represent a delay in gonorrhea detection because of decreased testing during the lockdown periods; however, this difference is unlikely to be a main factor for the observed increase in diagnoses because the largest increases in testing primarily occurred before all lockdown restrictions were removed (i.e., from 2020 Q2 to Q3 and 2021 Q1 to Q3; Figure 1, panel A).Furthermore, 18 months after lockdowns ended, increases in gonorrhea diagnoses continued to outpace increases in testing, corresponding to increasing test positivity.In addition, gonorrhea in heterosexual men is likely to cause symptomatic urethritis, which might cause those persons to seek earlier treatment at SHS.Although we did not have access to data on symptoms for confirmation, the increase in diagnoses observed in heterosexual men suggests an increase in incident infection and not just a delay in detection.
The sexual behavior of young persons was most adversely affected by COVID-19-related restrictions (4).After all lockdown restrictions were removed during summer 2021, the return of in-person attendance at higher education institutions might have provided increased opportunities for new and frequent changing of sexual partners.The potential change to higher STI risk behaviors could perhaps help explain the observed increases and is similar to reports from other countries in Europe in which gonorrhea diagnoses increased in 2022 among young persons of average university age (5)(6)(7)(8).
Young persons were affected the most by disruptions to SHS caused by lockdown measures (9).Testing by using online services increased, but evidence of access inequality existed; those 15-19 years of age were less likely to access testing through this route (10).We have shown that testing levels in young persons remained lower in 2022 than during the prepandemic period, suggesting that potential undiagnosed cases contributed to observed increases in gonorrhea.Messaging focused on the importance of regular STI testing, especially for young persons with new partners, could help address disease transmission resulting from undiagnosed cases.Public health messaging directed at young persons was published to coincide with the start of the 2023-24 academic year (11).
In conclusion, the increase in gonorrhea diagnoses was widespread in England after removal of all COVID-19 lockdown restrictions.It remains to be seen whether increases in gonorrhea diagnoses will be short-lived because of restrictions removal, whether pre-COVID-19 pandemic diagnoses levels will resume, or whether another trend will be observed.Continued close surveillance, a better understanding of the factors leading to the increase in gonorrhea diagnoses, and public health messaging (particularly to young persons) are needed to focus efforts on gonorrhea transmission control and prevention.

About the Author
Ms. Fountain is a senior STI surveillance and prevention scientist at the UK Health Security Agency.Her research is focused on real-time and enhanced surveillance of STIs in England and responding to changes in baseline circulation.

Figure 1 .
Figure 1.Total number of gonorrhea diagnoses and tests and percent test positivity in study of rebound of gonorrhea after lifting of COVID-19 preventive measures in England, January 1, 2019-December 31, 2022.A) Total number of diagnoses and tests.Bars indicate the total number of gonorrhea diagnoses; purple line indicates the total number of gonorrhea tests.B) Percent positivity of gonorrhea tests.Q, quarter.Scales for the y-axes differ substantially to underscore patterns but do not permit direct comparisons.

Table .
Numbers of persons with gonorrhea diagnoses who attended sexual health services according to gender and sexual orientation in study of rebound of gonorrhea after lifting of COVID-19 preventive measures, England* *Preventive measures were lifted in July (quarter 3) of 2021.MSM, gay, bisexual and other men who have sex with men; WOSW, women who only have sex with women; WSM, women who have sex with men.